AHM-510 | What Accurate AHM-510 Test Question Is

NEW QUESTION 1
One provision of the Mental Health Parity Act of 1996 (MHPA) is that the MHPA prohibits group health plans from

• A. Setting a cap for a group member's lifetime medical health benefits that is higher than the cap for the member's lifetime mental health benefits
• B. Imposing limits on the number of days or visits for mental health treatment
• C. Charging deductibles for mental health benefits that are higher than the deductibles for medical benefits
• D. Imposing annual limits on the number of outpatient visits and inpatient hospital stays for mental health services

Answer: A

NEW QUESTION 2
Certificate of need (CON) laws apply to health plans in a variety of ways, depending upon the state. By definition, CON laws are laws that are designed to

• A. Regulate the construction, renovation, and acquisition of healthcare facilities as well as the purchase of major medical equipment in a geographical area
• B. Protect commerce from unlawful restraint of trade, price discrimination, price fixing, reduced competition, and monopolies
• C. Determine benefit payments when a person is covered by more than one plan, such as two group health plans
• D. License and regulate health plans that wish to establish and operate an HMO

Answer: A

NEW QUESTION 3
TRICARE, a military healthcare program, offers eligible beneficiaries three options for healthcare services: TRICARE Prime, TRICARE Extra, and TRICARE Standard. With respect to plan features, both an annual deductible and claims filing requirements must be met, regardless of whether care is delivered by network providers, under

• A. TRICARE Prime and TRICARE Extra only
• B. TRICARE Extra and TRICARE Standard only
• C. TRICARE Standard only
• D. None of these healthcare options

Answer: C

NEW QUESTION 4
One typical difference between a for-profit health plan's board of directors and a not-for-profit health plan's board of directors is that the directors in a for-profit health plan

• A. Can serve on the board for a period of no more than ten years, whereas the terms of service fora not-for-profit board's directors are usually unlimited by the director's age or by a preset maximum number of years of service
• B. Must participate in raising capital for the health plan, whereas a not-for-profit board's directors are prohibited from participating directly in raising capital for the health plan
• C. Are directly accountable to shareholders, whereas a not-for-profit board's directors are accountable to plan members and the community
• D. Are not compensated for board participation, whereas a not-for-profit board's directors are compensated for board participation

Answer: C

NEW QUESTION 5
Any willing provider laws have their share of proponents and opponents. Arguments commonly made in opposition to any willing provider laws include

• A. That such laws reduce the number of providers in a health plan's network
• B. That such laws limit consumer choice to coverage options that are more costly than networkbased plans
• C. That such laws encourage providers to offer discounts in exchange for patient volume
• D. All of the above

Answer: B

NEW QUESTION 6
One federal law amended the Social Security Act to allow states to set their own qualification standards for HMOs that contracted with state Medicaid programs and revised the requirement that participating HMOs have an enrollment mix of no more than 50% combined Medicare and Medicaid members.
This act, which was the true stimulus for increasing participation by health plans in Medicaid, is called the

• A. Omnibus Budget Reconciliation Act of 1981 (OBRA-81)
• B. Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
• C. Employee Retirement Income Security Act of 1974 (ERISA)
• D. Federal Employees Health Benefits Act of 1958 (FEHB Act)

Answer: A

NEW QUESTION 7
The Surrey Medical Supply Company was formed as a limited partnership. In this partnership, Victoria Lewin is one of the limited partners and Oscar Gould is a general partner. This information indicates that, with respect to the typical characteristics of limited partnerships,

• A. M
• B. Lewin has more freedom to opt out of the partnership than does M
• C. Gould
• D. M
• E. Lewin has more liability for the debts of Surrey than does M
• F. Gould
• G. both M
• H. Lewin and M
• I. Gould participate in the day-to-day management of Surrey
• J. the partnership will continue upon the death of M
• K. Gould, whereas it will end with the death of M
• L. Lewin

Answer: A

NEW QUESTION 8
Brighton Health Systems, Inc., a health plan, wants to modify its advertising and marketing materials to avoid liability risk under the principle of ostensible agency. One step that Brighton can take to reduce the likelihood of being liable for provider negligence under the theory of ostensible agency is to

• A. Guarantee the quality of medical care provided to Brighton members
• B. Use advertising materials which state that Brighton itself provides healthcare
• C. Add disclaimers to advertising materials indicating that only physicians and not Brighton make medical decisions
• D. Use advertising materials to characterize Brighton's role as providing physicians, hospitals, and other healthcare professionals rather than arranging for healthcare.

Answer: C

NEW QUESTION 9
Health maintenance organizations (HMOs) seeking federal qualification under the HMO Act of 1973 and its amendments must meet requirements in four basic operational areas. One operational requirement for qualification is that an HMO must

• A. Ensure that at least 1/3 of its policy-making body is comprised of HMO members
• B. Ensure that there is adequate representation of underserved communities on its policy-making body
• C. Have an ongoing quality assurance program that meets the requirements of the Centers for Medicaid & Medicare Services (CMS), stresses health outcomes, and provides for review by health professionals
• D. Test, safeguard, and promote quality of care by following detailed programmatic techniques that are explained in CMS's Federally Qualified HMO (FQHMO) Manual

Answer: C

NEW QUESTION 10
The following statements are about the Federal Employees Health Benefits Program (FEHBP), which is administered by the Office of Personnel Management (OPM). Three of the statements are true and one statement is false. Select the answer choice that contains the FALSE statement.

• A. For every plan in the FEHBP, OPM annually determines the lowest premium that is actuarially sound and then negotiates with each plan to establish that premium rate.
• B. Once a health plan has submitted its rate proposals for a contract year to the OPM, it cannot adjust its premium rate for any reason.
• C. To cover its administrative costs, OPM sets aside 1% of all FEHBP premiums.
• D. Each spring, OPM sends all plan providers its call letter, a document that specifies the kinds of benefits that must be available to plan participants and cost goals and procedural changes that the plans need to adopt.

Answer: A

NEW QUESTION 11
The Westchester Health Plan is using a pricing strategy that involves setting a low price in a highly price-sensitive market to stimulate revenue growth. In following this strategy, Westchester is sacrificing short-term profits for fast growth in selected markets. This information indicates that Westchester is following the pricing strategy known as

• A. Market skimming
• B. Buying market share
• C. Price skimming
• D. Unitary pricing

Answer: B

NEW QUESTION 12
Arthur Dace, a plan member of the Bloom Health Plan, tried repeatedly over an extended period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr. Dace informally surveyed other Bloom plan members and found that many people were experiencing similar problems getting an appointment with this particular provider. Mr. Dace threatened to take legal action against Bloom, alleging that the health plan had deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making it difficult for patients to make appointments with Dr. Pyle.
Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR)
method that is quicker and less expensive than litigation. Under this ADR method, both Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who issued a decision that Bloom's utilization management practices in this case did not constitute a form of abuse. The panel's decision is legally binding on both parties.
This information indicates that Bloom resolved its dispute with Mr. Dace by using an ADR method known as:

• A. Corporate risk management
• B. An ombudsman program
• C. An ethics committee
• D. Arbitration

Answer: D

NEW QUESTION 13
The following situations illustrate per se violations of federal antitrust laws:
Situation A - Two groups of providers agreed among themselves that each provider will do business with health plans only on a fee-for-service basis.
Situation B - In order to avoid competing with each other, two independent, competing physicianhospital organizations (PHOs) divide the geographic areas in which they will market their services.
From the following answer choices, select the response that correctly identifies the types of per se violations illustrated by these situations.

• A. Situation A: price fixing; Situation B: horizontal division of markets
• B. Situation A: price fixing; Situation B: tying arrangement
• C. Situation A: horizontal group boycott; Situation B: horizontal division of markets
• D. Situation A: horizontal group boycott; Situation B: tying arrangement

Answer: A

NEW QUESTION 14
In 1994, the Department of Justice (DOJ) and the Federal Trade Commission (FTC) revised their 1993 healthcare-specific antitrust guidelines to include analytical principles relating to multiprovider networks. Under the new guidelines, the regulatory agencies will use the rule of reason to analyze joint pricing activities by competitors in physician or multiprovider networks only if

• A. Provider integration under the network is likely to produce significant efficiencies that benefit consumers
• B. The providers in a network share substantial financial risk
• C. The combining of providers into a joint venture enables the providers to offer a new product
• D. All of the above

Answer: A

NEW QUESTION 15
One example of health plan's influence on the practice of medicine is that, during the past decade, the focus of healthcare has moved toward , which is designed to reduce the overall need for healthcare services by providing patients with decision-making information.

• A. Demand management
• B. Managed competition
• C. Comprehensive coverage
• D. Private inurement

Answer: A

NEW QUESTION 16
Third party administrators (TPAs) provide various administrative services to health plans or groups that provide health benefit plans to their employees or members. Many state laws that regulate TPAs are based on the NAIC Third Party Administrator Model Statute. One provision of the TPA Model Law is that it

• A. Prohibits TPAs from performing insurance functions such as underwriting and claims processing
• B. Prohibits TPAs from entering into an agreement under which the amount of the TPA's compensation is based on the amount of premium or charges the TPA collects
• C. Requires TPAs, upon the termination of a TPA agreement with a group, to immediately transfer all its records relating to the group to the new administrator
• D. Requires TPAs to notify the state insurance department immediately following any material change in the TPA's ownership or control

Answer: D

NEW QUESTION 17
State X issued a nonresident license to Tamara Pensky, a sales representative of the Verity Health Plan. In doing so, State X imposed a countersignature requirement, which requires that

• A. An officer of Verity sign a written statement which indicates that Verity appoints M
• B. Pensky as an agent who is authorized to market Verity's products
• C. An officer of Verity sign a written statement which certifies that Verity has investigated M
• D. Pensky's qualifications and background and believes she is trustworthy and competent
• E. Applications solicited by M
• F. Pensky must be signed by an individual who holds a resident License
• G. Applications solicited by M
• H. Pensky must be signed by an officer of Verity

Answer: C

NEW QUESTION 18
Greenpath Health Services, Inc., an HMO, recently terminated some providers from its network in response to the changing enrollment and geographic needs of the plan. A provision in Greenpath's contracts with its healthcare providers states that Greenpath can terminate the contract at any
time, without providing any reason for the termination, by giving the other party a specified period of notice.
The state in which Greenpath operates has an HMO statute that is patterned on the NAIC HMO Model Act, which requires Greenpath to notify enrollees of any material change in its provider network. As required by the HMO Model Act, the state insurance department is conducting an examination of Greenpath's operations. The scope of the on-site examination covers all aspects of Greenpath's market conduct operations, including its compliance with regulatory requirements. The contracts between Greenpath and its healthcare providers contain a termination provision known as

• A. An 'economic credentialing' termination provision
• B. A 'breach of contract' termination provision
• C. A 'fair procedure' termination provision
• D. A 'without cause' termination provision

Answer: D

NEW QUESTION 19
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